Case 12 - motor difficulties

Question 1

Childs gait pattern - when does it resemble adult gait

Answer 1

• 3 years - resembles
• Adult gait and posture - 8 years old

Question 2

Normal gait variations that can occur during childhood

Answer 2

• Intoeing - femoral torsion or tibial torsion
• Bowlegs - birth to early toddler, resolves by 18 months (often + out toe)
• Knock knees - associated with intoeing, resolve by 7 years
• Flat feet - normal flexible foot and arch, resolves by 6 years

Question 3

Femoral torsion vs tibial torsion appearance of intoeing

Answer 3

• Femoral - knees and feet point inwards (commonest aged 3-8yrs)
• Tibial - knees point forward, feet point inwards

Question 4

Spastic hemiplegia gait

Answer 4

• Arm flexed, adducted, internalluy rotated
• Leg extended, stiff and plantar flexion
• Leg dragged in circumduction

Can be caused by cerebral palsy or acquired brain lesions eg stroke

Question 5

Spastic diplegia gait

Answer 5

• Tightness of adductors pulls knees together
• Legs cross midline –> scissoring gair
• Dragging and circumduction of both legs

Cerebral palsy can cause

Question 6

Cause of waddling (trendelenburg gait) in children

Answer 6

• Hip pain eg DDH, SCFE
• Perthes disease
• Proximal myopathy
• Duchenne MD

Question 7

What is cerebral palsy?

Answer 7

• Umbrella term for permanent disorder of motor movement an or posture due to non-progressive abnormality of devloping brain
• = problem is static but motor, neuro and functional impairments may change over time

Question 8

Most appropriate investigation to do if suspecting cerebral palsy

Answer 8

• MRI brain and spine
• Identify any underlying insults to child brain
• If difficult neonatal course and clinical signs of cerebral palsy often periventricular leukomalacia is apparent

Question 9

MDT involved with children who have cerebral palsy

Answer 9

• Audiology - screen hearing
• Occupational therapy
• Orthotics - splints, correct resting position of joint
• Physiotherapy - assess gait, ROM, advise on stretches etc
• Speech and language therapy - can cause speech problems and swallowing assessment

Question 10

What next steps if splints/supportive footwear are not helping position of gait and causing pain?

Answer 10

• Analgesia - eg muscle rubs or oral
• Contact orthotics to review splint
• Orthopaedics referral - mechanical problem persisting, advice re surgery etc

Question 11

Further management after splints tried for cerebral palsy

Answer 11

• Botox therapy - botulinum toxin A to reduce excess tone (hip adductors)
• Serial casting - feet and lower legs to try and correct abnormal position

Question 12

Co-morbidities associated with cerebral palsy

Answer 12

• Autism
• ADHD
• Epilepsy
• Learning difficulties
• Can also have problems sleeping due to spasticity, pain, night time splints pain, central causes

Question 13

Causes of cerebral palsy

Answer 13

Antenatal:
* Maternal infection
* Trauma during pregnancy

Perinatal:
* Birth asphyxia
* Pre-term

Post natal:
* Meningitis
* Severe neonatal jaundice
* Head injury

Question 14

Types of cerebral palsy

Answer 14

• Spastic - hypertonia, damage to UMN
• Dyskinetic - problems controlling muscle tone, hypo and hypertonia, damage to basal ganglia –> involuntary movements and oromotor problems
• Ataxic - damage to cerebellum
• Mixed

Question 15

Patterns of cerebral palsy

Answer 15

• Monoplegia - one limb
• Hemiplegia - one side
• Diplegia - four limbs, mostly legs
• Quadriplegia - all 4 limbs, severely